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Seven things you should know about optimal team practice

Sobel, Jonathan, DMSc, MBA, PA-C, DFAAPA, FAPACVS

Journal of the American Academy of PAs: May 2019 - Volume 32 - Issue 5 - p 12–13
doi: 10.1097/01.JAA.0000554747.39429.94
From the AAPA
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Jonathan Sobel is president and chair of the board of directors of the American Academy of PAs, and senior administrative director of PA Services at Northwell Health in New York City. The author has disclosed no other potential conflicts of interest, financial or otherwise.

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As we begin to see the introduction of state legislation to modernize physician assistant (PA) practice statutes in accordance with the American Academy of PAs' (AAPA's) tenets of optimal team practice (OTP), opponents are sure to stir up doubts about what OTP will mean for PAs, patients, other healthcare providers, and employers. Before you buy into their claims, consider the following facts about OTP.

1. OTP is about reducing unnecessary administrative constraints on PA practice.

OTP will give PAs, physicians, and other healthcare providers the flexibility they need to work together to provide high-quality care. OTP seeks three changes:

  • to eliminate the legal requirements for a PA to have an agreement with a specific physician in order to practice
  • to ensure that PAs have a say in the regulation of their profession
  • to let PAs take part in the same payment arrangements that are already available to NPs and physicians.

These changes would apply to and affect all PAs, regardless of their work setting or specialty.

2. OTP is about PAs being responsible for the care they provide.

PAs practice medicine as licensed medical professionals, yet legally they are not fully responsible for the decisions they make. Physicians are required to take responsibility for PA actions, even when they are not directly involved in the care of a patient or being compensated for this added liability. Today, PAs practice in a highly autonomous fashion as part of teams working in new care delivery models. The vestigial concept of physician supervision has been replaced by collaboration. Members of healthcare teams all bring their expertise together for the benefit of the patient. Eliminating the legal requirement for a PA to have an agreement with a specific physician in order to practice is how OTP modernizes PA practice to be consistent with the way healthcare is now delivered.

3. OTP will not change a PA's scope of practice.

Scope of practice describes the medical procedures, actions, and processes that clinicians are permitted to undertake, in keeping with the terms of their professional license. Scope of practice is limited to that which the law allows for specific education and experience, and specific demonstrated competency.

Within the legal bounds of scope of practice, personal scope of practice is further defined by clinician experience. As practice changes and providers gain additional skills and experience, their scope changes. As professionals and licensees, PAs limit their own personal scope of practice to those activities and procedures for which they are adequately prepared by training and experience. Failure to do so puts the PA at risk for professional liability or disciplinary action. Scope can be further defined by an employer. In licensed facilities, for example, PAs generally are subject to privileging processes to determine their scope of practice.

The requirement to have an agreement with a specific physician has no bearing on what a PA is competent to do, and eliminating that requirement will have no bearing on a PA's competence. If a PA is not qualified to harvest veins in cardiothoracic surgery, for example, OTP will not make that PA qualified or give the PA permission to perform that procedure.

OTP will free employers, physicians, and PAs to make decisions about healthcare teams based on the needs of patients and the skills and experience of the team members. It will put supervisory, collaboration, and similar decisions where they belong: at the practice level.

Eliminating the requirement for an agreement with a specific physician also will make it easier for PAs to practice in rural and medically underserved communities, and allow more PAs to provide volunteer medical services and respond to disasters and emergencies—conditions in which it is sometimes difficult or impossible to execute an agreement between a PA and physician.

4. OTP will make PAs responsible for their own profession.

This is not a new or novel concept. In every state, medical boards composed of physicians regulate physician practice. Boards composed of nurses do the same for nurses, and pharmacists, podiatrists, and physical therapists each have their own boards comprising members of their own professions. In five states, PA boards composed of PAs have been in place for years. Regulatory boards are composed of members of the profession being regulated for good reason. It is difficult, if not impossible, for someone who has not been educated or practiced in a profession to understand what its members can safely do and should be permitted to do. Further, they would have no insight into the issues facing members of the profession, or how to craft potential solutions.

OTP simply seeks to extend the principle of professional self-regulation to PAs in every state. And although it may not be financially feasible for every state to create a separate PA board, every state should at least have PAs and physicians who work with PAs as members of the medical board that regulates PA practice in the state.

5. An OTP state legislative model is available.

OTP was adopted by the AAPA House of Delegates as amendments to AAPA's Guidelines for State Regulation of PAs. Within a year, those changes were incorporated into model state legislation for PAs by the volunteer PAs who serve on AAPA's Government Relations and Practice Advancement Commission.

The guidelines and model state legislation for PAs are available to state legislators and staff, as well as to PAs in professional societies at the state level—and, of course, to all AAPA members. Note that these are guidelines and a model; decisions about what is possible in each state can and almost certainly will vary.

6. Under OTP, new graduate PAs do not need special rules.

There have been some calls for special rules for new graduate PAs, such as a requirement for an agreement with a physician for the PA's first year or two of practice. As with any new professional, recent graduate PAs will almost certainly have a supervisor in their first job. And, like all healthcare providers—new graduate or not—they will always be obligated to stay within scope of practice limitations based on their experience and education. Signing an agreement to practice with a specific physician provides no additional benefit to patients.

7. The federal government has already expressed support for the three critical elements of OTP.

In December 2018, the US departments of Health and Human Services (HHS), Treasury, and Labor issued a joint report examining recommendations to improve healthcare marketplace competition.1 The report includes several recommendations to improve PA practice and remove barriers to PA licensure. Consider the following statements from the report:

  • “[R]igid ‘collaborative practice agreement’ requirements can impede collaborative care rather than foster it because they limit the ability of healthcare professionals to adapt to varied healthcare demands, thereby constraining provider innovation in team-based care.”1
  • “The risk of anti-competitive harm may be even greater when the regulatory board that imposes [scope of practice] restrictions on one occupation is controlled by members of another, overlapping occupation that provides complementary or substitute services, and the board members are themselves active market participants with a financial stake in the outcome.”1
  • “The federal government and states should consider accompanying legislative and administrative proposals to allow non-physician [...] providers to be paid directly for their services where evidence supports that the provider can safely and effectively provide that care.”1

Those who suggest we give up because “it's too hard” to change the rules at the federal level may want to investigate the changing opinions of not only HHS but also the Federal Trade Commission, which has spoken out against nonevidence-based practice restrictions on PAs and NPs imposed by medical boards composed primarily of physicians.2

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REFERENCES

1. US Department of Health and Human Services, US Department of the Treasury, US Department of Labor. Reforming America's Health Care System Through Choice and Competition. Washington, DC; December 2018:32–36.
2. Iowa Board of Physician Assistants, Proposed New Rules: 645-327.8: Definition of physician supervision of a physician assistant. Office of Policy Planning, Bureau of Economics, and Bureau of Competition. http://www.ftc.gov/system/files/documents/advocacy_documents/ftc-staff-comment-professional-licensure-division-iowa-department-public-health-regarding-proposed/v170002_ftc_staff_comment_to_iowa_dept_of_public_health_12-21-16.pdf. Accessed March 18, 2019.
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